Conversation with Dr. Britt

Subsequent to Dr. Britt’s address to the Association of Veterans Administration Surgeons (AVAS) in April 2016, Dr. Lipshy interviewed the ACS Past-President and Chair of the ACS Committee on Health Care Disparities. Dr. Britt shared his views on the state of patient safety. A summary of that interview follows.

You stated in your address to the AVAS that in spite of our best efforts, relatively little progress has been made in the prevention of adverse events in health care. With all of our technology and awareness, why can’t we close the gap on patient safety?

There is no system. There is no communication. We have a dysfunctional system. We have too many distractions. It is a ruse. In the time out, there is no concentration on the actual tasks. I believe that we are not systematic. You need to fix the system first. We are a disparate federation consisting of insurance providers, hospitals, nurses, and medical providers. We are not integrated. To fix the problem, we need to integrate the system. We need to all work together to correct this problem.

Do you believe adverse events occur because we are simply not smart enough to do what we are supposed to do, or is there more to the story?

You are asking the wrong question. You need to ask, “Why are surgeons not doing it right in the first place?” At the end of the day, you need a system that corrects itself for these types of issues. You wouldn’t work for Vince Lombardi and keep making mistakes. If you become an outlier, you get a chance to redeem yourself. You get a chance for remediation. You relearn, or you move out. You are no longer on our team. You may find another place where you will fit in and function, but not with us. The true system should be able to effectively address these adverse effects. You cannot give the system a pass when it allows this to happen.

Is training in the effects of team dynamics, communication, and human factors the answer, or are they a portion of the equation?

The answer is both. These are all factors in the equation. Team training is only one component—a part of the equation. Communication is clearly a key aspect. You cannot fix this without improving communication. But this should not be a top-down process. There must be equal footing. We need a circular, cooperative communication process. We need to reconfigure the way we communicate. If the Institute of Medicine reports that adverse events have increased from 98,000 to 200,000, then we have a problem. Why? It is likely that optimal communication has not been achieved.

Are we making a mistake in trying to apply high-reliability organization (HRO) models, given that health care delivery is more complicated and dependent on human factors, or are we simply applying those models incorrectly?

We may not be hitting a home run, but we need to build upon these results. We need to embrace this and move on. [Patient safety] requires a multidisciplinary attack. Team training is just one of the components. You cannot minimize these results.

I’ve said it before—aviation is not the same as medicine. Medicine is much more complex. Aviation typically has a relatively stable environment when planes are operational. You get a weather report, and it changes infrequently. In aviation you don’t have to worry about comorbidities or typically worry about secondary changes. There is no parallel to what we have in medicine. There are always unknowns in medicine. We are just beating ourselves up too much over this. We need to move on and build a new model for this new health care world.

Does the presence of several co-existing units help or hinder team training in health care?

Is it disparate? We need a monolithic communication network. We need to talk to one another as if we are all on the same team and not different teams.

Is the term “captain of the ship” a misnomer in health care? Does the “captain of the ship” exist in a health care HRO?

I don’t think we can think of ourselves as captains of the ship. That title just does not fit any longer. I think of a surgeon as being the key member on a relay team. I am not captain of the team, but I am one of the team members. However, after the baton is passed off, you cannot relax. The oversight of the entire process is the responsibility of the surgeon. So wherever the patient is coming from or going to, the surgeon needs to provide that oversight; whether it’s in the clinic, the operating room, the PACU [post-anesthesia care unit], the ward, or wherever.

In a 2015 General Surgery News letter, Linda L. Wong, MD, FACS, described her experience after she saved a patient who was exsanguinating from a ruptured hepatic tumor, but left behind a single sponge (out of 120 used). In the end, she states that she was humiliated in spite of her heroic efforts.* Do you believe that the focus on raw data, single negative events, or following the checklist instead of focusing on the safe practice culture in general is distracting staff from progress in the area of patient safety improvement? If so, what can be done to rectify this prevailing concept of punishing people for a single event?

In the case you cite involving Dr. Wong, the data are not being taken into context. You must always view the data in the context of the patient and the environment. For example, everyone knows that the chance of leaving a foreign body in a patient is highest in the obese patient, the emergency case where a lot of blood is lost, and when there is a radical change in the surgery process/strategy. Now, don’t get me wrong, there is no excuse for a never event. We can never have a case of removing the wrong leg or wrong body part. (This response was in reference to a personal conversation held with Dr. Wong regarding events summarized in the November 2015 General Surgery News article.)

What do we do when it is obvious that the event is taken out of context with the entire case? In many cases physicians believe that no one really understood what occurred and were simply told that an unforgivable never event happened.

In these cases, at some point someone in charge should have taken over. You need the CEO [chief executive officer] or chief of staff to take control and put the incident into context. They needed to say, “This is not just a simple data point. Let’s work together to see how we can avoid future similar circumstances.” You need another level of oversight to step in and not rake staff over the coals unnecessarily. You need to focus on the process and not the individual when such mistakes are made. That is how a safety culture is created.

Is the EHR the answer to all of our problems, as many outside agencies insist?

I think that the EHR could be the answer, but in its current state, it is not. We should have a mandate that all health care records communicate with each other. The EHR should assist us with evaluating quality metrics. If I could design the ultimate EHR, I would design one that interfaces with all records and provides appropriate benchmarks with good quality metrics.

So, why don’t we have this type of EHR yet?

It’s expensive. But we need the government to step in and mandate that these changes be made. We need to make sure that our EHRs are a part of an integrated system that talks to everyone and provides the data we need.

Is poor leadership the reason behind our failure to improve patient safety? Should hospital executives be trained similarly to those in other HROs?

It is important to understand failure of leadership when attempting to understand failure of maintaining safety, so yes, all hospital executives should be well versed in patient safety initiatives and undergo the same training as the staff undergoes. But remember, health care is far more complex than most other industries so the training should not be the same as in other industries.

One of my colleagues asked me why the payment models appear to reward CEOs and insurance companies in manners that are not aligned with patient safety and culture. Do you think that if CEOs were penalized for every adverse event at their hospital it would promote culture change?

I think that health care workers know that CEOs make money inconsistent with others in health care. Their compensation should be affected by or linked to patient outcomes.

Hippocrates said, “first, do no harm,” but is that the same as “zero patient harm”? Does a focus on zero harm help or hinder our cause in improving safety in health care?

I do not disapprove in general of the notion that we should have zero harm, but only when referring to never events. Everyone needs to remember that this environment is simply too complex to avoid any harm, but there is nothing wrong with this concept as a global mission. We just have to remember we cannot avoid all complications. However, we should never have never events—wrong site, wrong side, wrong patient, and so on. We simply cannot allow that to happen to our patients.

How do you and your department encourage a safety culture at your institution?

The culture of safety is discussed vigorously at every M & M [morbidity and mortality] conference, at every patient’s bedside, in all discussions about patients, on daily rounds, with the intent that no one forgets that patient safety is always our goal.

Why do we, as a surgical community, consistently argue about the validity of the data rather than acknowledge that a problem exists, move on, and seek solutions that work in departments?

We have not told the story very well. Surgeons must remember that the safety environment was brought about by surgeons. We created that safety culture long ago. Surgeons have handed that responsibility to others and need to go back to those principles. We all need to realize that being an outlier has consequences. Everyone knows there are three principles surgeons must live by. Clinical excellence and strong education are the first two. The third is good stewardship of resources, which includes effective utilization of resources in order to enhance quality care and patient safety.